Milestone Two: Reimbursement
Describe the impact of the departments that utilize reimbursement data
Reimbursement is a vital element in healthcare organizations. In their analysis, Eldenburg, Krishnan, and Krishnan (2017) maintain that the profitability and sustainability of a healthcare facility depend on its effectiveness in managing the reimbursement process. Consequently, poor management of the reimbursement process at the Adventist Hospital will lower its ability to offer quality and reliable healthcare services due to inadequate finances.
Importantly, each department in a healthcare facility influences the reimbursement process in terms of the timeline and the amount of money channeled in and out of the hospital system. In this respect, all departments within the Adventist Hospital that utilize reimbursement data must ensure that this information is correctly captured at the departmental level. It is vital to remember that the reimbursement information captured at the departmental level is used to compute the overall reimbursement status of the entire healthcare facility.
If the reimbursement process is not managed appropriately at these departments, Adventists Hospital’s revenue stream will be affected adversely. In particular, poor management of reimbursement at the departmental level results in a reduction in the collection rates. This decline in collection rates will negatively influence the provision of services that relies solely on the finances generated through reimbursement. In this respect, effective management and monitoring of the reimbursement process at the departmental levels enables the hospital to have a niche-level control of all its revenue attributes. Moreover, this move also enhances the quality of services delivered to patients.
What type of audit would be necessary to determine whether the reimbursement impact is reached fully by these departments? How could the impact of these departments on pay-for-performance incentives be measured?
Auditing is a vital activity that enables healthcare organizations to review their operations and address any identified inconsistencies appropriately. According to Garczynski (2008), it is advisable from healthcare facilities to conduct frequent audits of their reimbursement processes to optimize revenue generation as well as to protect the patients from exorbitant charges. As earlier noted, reimbursement affects the overall financial stability of medical facilities and the quality of services that they offer. As a result, a frequent review of the Adventist Hospital’s reimbursement records will significantly assist the institution in identifying flaws in their reimbursement systems. Addressing these flaws will enhance the hospital’s revenue generation abilities.
As a result, conducting internal audits is one of the instrumental strategies that the Adventist Hospital can utilize to determine whether the reimbursement impact is reached fully by its various departments. In this type of auditing approach, an internal auditor examines if the preset reimbursement goals for each department have been attained. The process includes scrutinizing the departmental reimbursement data and comparing it to the pre-established goals. Apart from assessing the attainment of these goals, the auditor should also evaluate the efficiency of the reimbursement process at each of these departments to ensure that any existing flaws are eliminated.
Importantly, it is advisable for the Adventist Hospital to ensure that it conducts such internal departmental audits regularly to attain an effective and reliable reimbursement system. This stance implies that the hospital should conduct regular follow–up audits to determine the progress of its reimbursement activities. In ascertaining the impact of its various departments on pay-for-performance incentives, the Adventist Hospital should utilize goal assessment approach. This method entails setting precise departmental objectives and measuring how pay-on service incentives influence their attainment. Precisely, this activity entails assessing departmental performance before the introduction of the pay-for-performance incentives and comparing this performance after the introduction of the incentives.
Assess the activities within each department at this healthcare organization for how they may impact reimbursement.
The Adventist Hospital is subdivided into various departments to attain efficiency in service provision. One of the key divisions at the Adventist Hospital is the clinical service unit where care offered to the patients. The department is responsible for documenting who provided care to the patients and why type o ace was rendered. As stated by Harrington (2015), the detail captured by the clinical department determines the details that will be used by the subsequent departments. Therefore, if the patient’s details are wrongly captured at this unit, it can result in delayed reimbursement due to detail mismatch.
The patient account department is another instrumental unit that impacts on the reimbursement process at the Adventist Hospital. Harrington (2015) points out that this department is responsible for collecting all the transactions that are recorded in the patient account through the chargemaster, producing a bill for the payer, and sending it to them. The success of this unit is determined by the accuracy of the details contained in the chargemaster. For that reason, inaccurate charge master details can result in complaints that subsequently delay reimbursement.
Another vital department is the health information management department, which is tasked with soft-coding of patients’ medical records. This section is characterized by activities such as assigning diagnosis codes, assigning procedure codes and developing a patient chart. The chart developed by the unit is sent to the patient account department for processing to the payer (Harrington, 2015). In this respect, inaccurate coding or delay in the chart development in this unit results in delayed or disputed reimbursements. The final department at the Adventist Hospital is administration unit. This department is responsible for reviewing all of the financial transactions at the Adventist Hospital. The measures put in place by this department affect the efficiency of the hospital’s reimbursement process.
Identify the responsible department for ensuring compliance with billing and coding policies. How does this affect the department’s impact on reimbursement at this healthcare organization?
The administration department is the one responsible for ensuring compliance with the billing and coding policies at the Adventist Hospital. The Adventist Hospital’s administration department has a special division within it made up of reimbursement experts who assess the institution’s billing activities and its compliance with the stipulated standards. This department significantly affects reimbursement at the Adventist Hospital since its operations ensure that the organization has an effective reimbursement system and policies in place.
References
Eldenburg, L. G., Krishnan, H. A., & Krishnan, R. (2017). Management Accounting and Control in the Hospital Industry: A Review. Journal of Governmental & Nonprofit Accounting, 6(1), 52-91.
Garczynski, M. F. (2008). Knowledge-Based Audits of Health Care Entities. Chicago: CCH Group.
Harrington, M. K. (2015). Health Care Finance and the Mechanics of Insurance and Reimbursement. Burlington: Jones & Bartlett Publishers.
